Reports Adult Ophthalmology Inpatient Consults at a Tertiary Care Teaching Hospital Ophthalmology consultation is commonly requested for inpatients in a tertiary hospital,1e4 and there is often lack of familiarity with ocular pathology among other medical professionals.3,5 This study was designed to identify the characteristics of inpatient consultations performed at an adult tertiary care hospital and recommend guidelines for developing an ophthalmology consult service and resident consult curriculum. In accordance with institutional review board guidelines, we reviewed the electronic health records of 974 inpatient ophthalmology consultations performed from October 2007 to October 2011. We recorded 116 unique reasons for requesting ophthalmology consultations. Five hundred ninety-six consults (61.2%) were initiated owing to a symptomatic patient complaint. Three hundred seventyeight patients (38.8%) were asymptomatic, and consults were requested to evaluate for presence or absence of a specific ocular finding or disease (e.g., papilledema, Wilson disease, diabetic retinopathy, ocular infection). The most frequent indications (>10 consultations each) are listed in Table 1 (available at www. aaojournal.org). Eighty-one patients (8.3%) underwent slit-lamp examination in an ophthalmology examination room for further evaluation. The remaining 893 patients (91.7%) had bedside examinations, including portable slit-lamp examination when indicated. A dilated fundus examination was performed in 850 patients (87.2%); 124 (12.8%) underwent an undilated anterior segment examination. In all, 212 inpatients (21.8%) required >1 ophthalmology visit during their hospital stay (mean, 1.5; range, 2e22 total visits). We recorded 198 different primary ophthalmologic diagnoses, with the most frequent (occurring >10 times) listed in Table 1. The most common primary medical diagnoses were malignancy, intracranial hemorrhage, and HIV infection (Table 1). The most common malignancies were acute myeloid leukemia (n ¼ 28), multiple myeloma (n ¼ 22), brain tumor (n ¼ 27), metastatic cancer (n ¼ 22), and others (n ¼ 13), including Hodgkin lymphoma, acute lymphoblastic leukemia, chronic lymphocytic leukemia, T-cell lymphoma, and breast cancer. An ophthalmic subspecialist was requested to examine 57 consults (5.9%), most commonly retina (43.9%), neuroophthalmology (22.8%) oculoplastics (14%), uveitis (8.8%), and cornea (7%). Of the 725 medical records listing the consulting service, internal medicine/hospitalist service was most frequent (37.1%), followed by neurosurgery (13.2%) and hematologyoncology (9.8%; Fig 1, available at www.aaojournal.org). Input from ophthalmology influenced management in 56.5% of consults. Figure 2 (available at www.aaojournal.org) lists the diagnostic investigations and therapeutic interventions performed. Initiation of topical ocular medication was recommended in 324 patients (33.3%), including lubricating drops (49.7%), antibiotic drops/ointment (34%), steroids (9.6%), and intraocular pressureelowering drops (6.8%). Systemic medications were initiated by ophthalmology in 75 patients (7.7%), neuroimaging
was ordered in 41 (4.2%), and laboratory investigations in 13 (1.3%). Twenty-nine patients (3%) underwent interventional procedures by ophthalmology, including operative procedures in the operating room (n ¼ 14), intravitreal or subtenons injection (n ¼ 4), corneal scraping and culture (n ¼ 4), tarsorraphy (n ¼ 3), anterior chamber paracentesis (n ¼ 3), and cyclophotocoagulation (n ¼ 1). Of 58 patients, 4 (6.9%) examined to rule out fungal endophthalmitis were positive for fungal chorioretinal lesions. None were symptomatic, and all 4 responded to intravenous antifungals with none requiring intravitreal medications. Of 26 patients, 4 (15.3%) with cytomegalovirus viremia had positive retinal findings. We evaluated 30 patients (10%) with systemic varicella infection who had zoster keratoconjunctivitis. Identifying the nature of common inpatient consultations and defining their management algorithms can help residency programs to identify areas for targeted education, especially for junior residents, who often are the first to examine the patient. The resident curriculum for inpatient consultations should include specific training in 4 areas. Examination Techniques. Residents should be taught a focused bedside ophthalmic examination using a portable slit lamp and indirect ophthalmoscope. Bedside evaluation skills should include bestcorrected visual acuity measurement with a handheld near and/or far visual acuity card; assessment of ocular motility and globe integrity in the setting of an orbital fracture; examination of patients with suspected periocular, orbital, or intraocular infections; evaluation of cranial nerve palsies; and evaluation of anterior-segment trauma. Of these patients, 91.7% had a bedside examination and most bedside examinations included a portable slit-lamp examination. Several patients could not be safely transported to an eye examination room owing to issues such as patients being in a monitored intensive care unit, intubated patients, or those with special infection control restrictions. Upon discharge, patients requiring follow-up care were scheduled in the outpatient ophthalmology clinic. Ophthalmic Manifestations of Common Inpatient Diseases. Junior residents should be educated to recognize ophthalmic manifestations of commonly encountered systemic diseases in an inpatient setting, including how to “rule out” a specific finding, as well as adverse ophthalmic reactions to systemic medications. Ophthalmic Testing, Treatment, and Procedures. Appropriate workup, imaging studies including neuroimaging, when to initiate ophthalmic and systemic medications, and how to identify indications for and perform procedures such as intravitreal injections, corneal scraping and culture, tarsorraphy, and anterior chamber paracentesis should incorporated into the curriculum. It is important to remember that these are highly specialized procedures only to be performed by trained ophthalmologists. Ocular Infections. Given the high potential for ocular morbidity if untreated, as well as the risk for mortality in diseases such as mucormycosis in immunocompromised patients, residents should be educated to diagnose ocular infections during a bedside examination with special emphasis given to fungal endophthalmitis, cytomegalovirus, and herpetic eye disease. The type of consultations encountered will be largely dictated by the nature of the dominant specialties at the parent hospital, comfort of the physicians with ophthalmic examination, as well as
1
Ophthalmology Volume -, Number -, Month 2014 demographics of the patient population. This also helps to identify sources of likely referrals based on the consulting service. The inpatient population in our study is composed of a significant number of immunocompromised patients, including solid organ and stem cell transplant patients, as well as patients with solid organ and hematologic malignancies. A significant proportion of consultations from transplant surgery and hematology-oncology were to evaluate for ocular infections and graft-versus-host disease. Similarly, a large proportion of consultations from neurology and neurosurgery were to evaluate for papilledema, cranial nerve palsies, and optic neuritis. It is essential to educate residents on the importance of adequate communication with the primary service. Electronic health record data can be used to improve resident training and adapt to changes in patient care. The inpatient consult service also offers the opportunity to recognize, document, and define emerging patterns of new diseases or changing ophthalmic associations of known diseases. Given the breadth of examination skills and the fund of knowledge required, a consultation service should include residents who have these skills (possibly mid to upper level residents) with appropriate attending coverage. This data-based curriculum incorporating the characteristics of adult inpatient consults can be helpful for both ophthalmology residents and nonophthalmic physicians.
DILRAJ S. GREWAL, MD ELIZABETH CHIANG, MD, PHD
2
ELIZABETH WONG, BS NICHOLAS J. VOLPE, MD PAUL J. BRYAR, MD Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Presented at: the Association for Research in Vision and Ophthalmology Annual Meeting in May 2012. Financial Support: Supported in part by an unrestricted grant from Research to Prevent Blindness, New York.
References 1. Bala C, Poon AC, Joblin P, McCluskey PJ. Ophthalmologists in teaching hospitals: do we make a difference to patient outcome? Clin Exp Ophthalmol 2001;29:59–63. 2. Carter K, Miller KM. Ophthalmology inpatient consultation. Ophthalmology 2001;108:1505–11. 3. Schachat AP, McDonnell PJ, Petty BG, et al. Ophthalmology consultations at a large teaching hospital. Metab Pediatr Syst Ophthalmol 1989;12:105–9. 4. Tajunisah I, Azida J, Zurina ZA, Reddy SC. Ophthalmology inpatient consultation: does it make a difference to inpatient management? Med J Malaysia 2009;64:130–3. 5. Harrison RJ, Wild JM, Hobley AJ. Referral patterns to an ophthalmic outpatient-clinic by general-practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease. BMJ 1988;297:1162–7.
Reports Table 1. Most Common Reasons (n>10) for Requesting an Ophthalmology Consultation
Reason for Consultation Blurred vision Trauma or orbital fracture on radiographic imaging Eye redness Eye pain Rule out fungal endophthalmitis Diplopia Rule out retinopathy (cardiac transplant protocol)* Loss of vision (transient or longstanding) Rule out papilledema Rule out ocular involvement from herpes zoster Periorbital swelling Rule out CMV retinitis Floaters Foreign body sensation Visual disturbances Visual field defect Flashes of light Primary ophthalmic diagnosis Normal ocular exam or finding questioned ruled out Orbital fracture without muscle entrapment Refractive error Corneal abrasion Dry eye Subconjunctival hemorrhage 6th cranial nerve palsy Preseptal cellulitis Cataract Nonproliferative diabetic retinopathy Optic disc edema Visual field defect Glaucoma Retinal hemorrhage Transient ischemic attack/amaurosis fugax Posterior vitreous detachment Bacterial conjunctivitis Blepharitis Exposure keratopathy Hypertensive retinopathy Primary medical diagnosis Malignancy Acute myeloid leukemia Multiple myeloma Brain tumor Metastatic cancer Others Intracranial hemorrhage HIV infection Facial/orbital fractures Diabetes (type I/II) Congestive heart failure Cerebrovascular accident Trauma Coronary artery disease Hypertension Intracranial aneurysm Ischemic cardiomyopathy Hydrocephalus
n
%
144 115 80 73 58 50 38 38 32 30 27 26 20 17 16 11 10
14.8 11.8 8.2 7.5 6.0 5.1 3.9 3.9 3.3 3.1 2.8 2.7 2.1 1.7 1.6 1.1 1.0
118 86 69 53 42 30 23 23 20 15 15 15 13 13 13 12 10 10 10 10
12.1 8.8 7.1 5.4 4.3 3.1 2.4 2.4 2.1 1.5 1.5 1.5 1.3 1.3 1.3 1.2 1.0 1.0 1.0 1.0
112 28 22 27 22 13 44 36 26 24 20 19 15 14 14 14 11 10
11.5 d d d d d 4.5 3.7 2.7 2.5 2.1 2.0 1.5 1.4 1.4 1.4 1.1 1.0
CMV ¼ cytomegalovirus. Total of 116 unique reasons. Most common primary ophthalmic diagnosis (n>10) total n ¼ 198. Most common primary medical diagnosis (n>10) total n ¼ 148. *Cardiac transplant protocol ¼ baseline fundus examination before receiving a heart transplant.
Figure 1. Inpatient services most commonly requesting an ophthalmology consultation. ENT ¼ ear, nose, and throat.
Figure 2. Diagnostic and therapeutic interventions performed by the ophthalmology service. CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; OCT ¼ optical coherence tomography.
2.e1
was ordered in 41 (4.2%), and laboratory investigations in 13 (1.3%). Twenty-nine patients (3%) underwent interventional procedures by ophthalmology, including operative procedures in the operating room (n ¼ 14), intravitreal or subtenons injection (n ¼ 4), corneal scraping and culture (n ¼ 4), tarsorraphy (n ¼ 3), anterior chamber paracentesis (n ¼ 3), and cyclophotocoagulation (n ¼ 1). Of 58 patients, 4 (6.9%) examined to rule out fungal endophthalmitis were positive for fungal chorioretinal lesions. None were symptomatic, and all 4 responded to intravenous antifungals with none requiring intravitreal medications. Of 26 patients, 4 (15.3%) with cytomegalovirus viremia had positive retinal findings. We evaluated 30 patients (10%) with systemic varicella infection who had zoster keratoconjunctivitis. Identifying the nature of common inpatient consultations and defining their management algorithms can help residency programs to identify areas for targeted education, especially for junior residents, who often are the first to examine the patient. The resident curriculum for inpatient consultations should include specific training in 4 areas. Examination Techniques. Residents should be taught a focused bedside ophthalmic examination using a portable slit lamp and indirect ophthalmoscope. Bedside evaluation skills should include bestcorrected visual acuity measurement with a handheld near and/or far visual acuity card; assessment of ocular motility and globe integrity in the setting of an orbital fracture; examination of patients with suspected periocular, orbital, or intraocular infections; evaluation of cranial nerve palsies; and evaluation of anterior-segment trauma. Of these patients, 91.7% had a bedside examination and most bedside examinations included a portable slit-lamp examination. Several patients could not be safely transported to an eye examination room owing to issues such as patients being in a monitored intensive care unit, intubated patients, or those with special infection control restrictions. Upon discharge, patients requiring follow-up care were scheduled in the outpatient ophthalmology clinic. Ophthalmic Manifestations of Common Inpatient Diseases. Junior residents should be educated to recognize ophthalmic manifestations of commonly encountered systemic diseases in an inpatient setting, including how to “rule out” a specific finding, as well as adverse ophthalmic reactions to systemic medications. Ophthalmic Testing, Treatment, and Procedures. Appropriate workup, imaging studies including neuroimaging, when to initiate ophthalmic and systemic medications, and how to identify indications for and perform procedures such as intravitreal injections, corneal scraping and culture, tarsorraphy, and anterior chamber paracentesis should incorporated into the curriculum. It is important to remember that these are highly specialized procedures only to be performed by trained ophthalmologists. Ocular Infections. Given the high potential for ocular morbidity if untreated, as well as the risk for mortality in diseases such as mucormycosis in immunocompromised patients, residents should be educated to diagnose ocular infections during a bedside examination with special emphasis given to fungal endophthalmitis, cytomegalovirus, and herpetic eye disease. The type of consultations encountered will be largely dictated by the nature of the dominant specialties at the parent hospital, comfort of the physicians with ophthalmic examination, as well as
1
Ophthalmology Volume -, Number -, Month 2014 demographics of the patient population. This also helps to identify sources of likely referrals based on the consulting service. The inpatient population in our study is composed of a significant number of immunocompromised patients, including solid organ and stem cell transplant patients, as well as patients with solid organ and hematologic malignancies. A significant proportion of consultations from transplant surgery and hematology-oncology were to evaluate for ocular infections and graft-versus-host disease. Similarly, a large proportion of consultations from neurology and neurosurgery were to evaluate for papilledema, cranial nerve palsies, and optic neuritis. It is essential to educate residents on the importance of adequate communication with the primary service. Electronic health record data can be used to improve resident training and adapt to changes in patient care. The inpatient consult service also offers the opportunity to recognize, document, and define emerging patterns of new diseases or changing ophthalmic associations of known diseases. Given the breadth of examination skills and the fund of knowledge required, a consultation service should include residents who have these skills (possibly mid to upper level residents) with appropriate attending coverage. This data-based curriculum incorporating the characteristics of adult inpatient consults can be helpful for both ophthalmology residents and nonophthalmic physicians.
DILRAJ S. GREWAL, MD ELIZABETH CHIANG, MD, PHD
2
ELIZABETH WONG, BS NICHOLAS J. VOLPE, MD PAUL J. BRYAR, MD Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Presented at: the Association for Research in Vision and Ophthalmology Annual Meeting in May 2012. Financial Support: Supported in part by an unrestricted grant from Research to Prevent Blindness, New York.
References 1. Bala C, Poon AC, Joblin P, McCluskey PJ. Ophthalmologists in teaching hospitals: do we make a difference to patient outcome? Clin Exp Ophthalmol 2001;29:59–63. 2. Carter K, Miller KM. Ophthalmology inpatient consultation. Ophthalmology 2001;108:1505–11. 3. Schachat AP, McDonnell PJ, Petty BG, et al. Ophthalmology consultations at a large teaching hospital. Metab Pediatr Syst Ophthalmol 1989;12:105–9. 4. Tajunisah I, Azida J, Zurina ZA, Reddy SC. Ophthalmology inpatient consultation: does it make a difference to inpatient management? Med J Malaysia 2009;64:130–3. 5. Harrison RJ, Wild JM, Hobley AJ. Referral patterns to an ophthalmic outpatient-clinic by general-practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease. BMJ 1988;297:1162–7.
Reports Table 1. Most Common Reasons (n>10) for Requesting an Ophthalmology Consultation
Reason for Consultation Blurred vision Trauma or orbital fracture on radiographic imaging Eye redness Eye pain Rule out fungal endophthalmitis Diplopia Rule out retinopathy (cardiac transplant protocol)* Loss of vision (transient or longstanding) Rule out papilledema Rule out ocular involvement from herpes zoster Periorbital swelling Rule out CMV retinitis Floaters Foreign body sensation Visual disturbances Visual field defect Flashes of light Primary ophthalmic diagnosis Normal ocular exam or finding questioned ruled out Orbital fracture without muscle entrapment Refractive error Corneal abrasion Dry eye Subconjunctival hemorrhage 6th cranial nerve palsy Preseptal cellulitis Cataract Nonproliferative diabetic retinopathy Optic disc edema Visual field defect Glaucoma Retinal hemorrhage Transient ischemic attack/amaurosis fugax Posterior vitreous detachment Bacterial conjunctivitis Blepharitis Exposure keratopathy Hypertensive retinopathy Primary medical diagnosis Malignancy Acute myeloid leukemia Multiple myeloma Brain tumor Metastatic cancer Others Intracranial hemorrhage HIV infection Facial/orbital fractures Diabetes (type I/II) Congestive heart failure Cerebrovascular accident Trauma Coronary artery disease Hypertension Intracranial aneurysm Ischemic cardiomyopathy Hydrocephalus
n
%
144 115 80 73 58 50 38 38 32 30 27 26 20 17 16 11 10
14.8 11.8 8.2 7.5 6.0 5.1 3.9 3.9 3.3 3.1 2.8 2.7 2.1 1.7 1.6 1.1 1.0
118 86 69 53 42 30 23 23 20 15 15 15 13 13 13 12 10 10 10 10
12.1 8.8 7.1 5.4 4.3 3.1 2.4 2.4 2.1 1.5 1.5 1.5 1.3 1.3 1.3 1.2 1.0 1.0 1.0 1.0
112 28 22 27 22 13 44 36 26 24 20 19 15 14 14 14 11 10
11.5 d d d d d 4.5 3.7 2.7 2.5 2.1 2.0 1.5 1.4 1.4 1.4 1.1 1.0
CMV ¼ cytomegalovirus. Total of 116 unique reasons. Most common primary ophthalmic diagnosis (n>10) total n ¼ 198. Most common primary medical diagnosis (n>10) total n ¼ 148. *Cardiac transplant protocol ¼ baseline fundus examination before receiving a heart transplant.
Figure 1. Inpatient services most commonly requesting an ophthalmology consultation. ENT ¼ ear, nose, and throat.
Figure 2. Diagnostic and therapeutic interventions performed by the ophthalmology service. CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; OCT ¼ optical coherence tomography.
2.e1
